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UCSF Nursing Dean Discusses Cardiac Care Study

December 18, 2009

Kathleen Dracup

Heart patients who receive specific instructions about how to respond to chest pain or heart attack symptoms still don’t seek immediate care, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

“Unfortunately, it’s an example once again of how knowledge doesn’t translate into behavior change,” said Kathleen Dracup, RN, DNSc, principal investigator of the study and dean of the UCSF School of Nursing.

In the study, Patient Response to Myocardial Infarction following a Teaching Intervention Offered by Nurses, researchers tested whether education about chest pain or a heart attack could lead patients at high risk for such conditions to summon emergency help more quickly.

Patients who received education learned what symptoms to watch for and what to do if the symptoms occurred. However, patients who later experienced such symptoms did not arrive at the hospital more quickly than patients who didn’t receive the education.

Dracup participated in a recent interview posted on HHS Healthbeat, a radio program sponsored by the U.S. Department of Health and Human Services. Below is a transcript of the discussion with Dracup about the study findings and the public health challenge in getting heart patients to access care more quickly.

Below is the transcript of audio interview:

We’re talking today with Kathleen Dracup, dean of the UCSF School of Nursing, about her study which was recently published in Circulation: Cardiovascular Quality and Outcomes. In this study, the research team found a gap between patient knowledge and behavior when responding to cardiac symptoms.

Q: One group of heart patients got specific instructions about how to respond to chest pain or other heart attack symptoms. When you looked at whether those patients got immediate care what did you find?

Dracup: We found that heart attack patients or patients that have heart disease do, in general, know many of the things they need to know in order to act appropriately. They know most of the cardiac symptoms and they understand that they need to seek care. We randomized people to a special group and gave them very explicit instructions and also tried to deal with some of the barriers that we know exist when patients are experiencing heart attack symptoms and either are too embarrassed to call 9-1-1 or they’re reluctant to label them as cardiac symptoms. So we did some role playing and we worked hard at addressing those barriers.

Unfortunately, what we found is that this is very difficult behavior to change. The patients who received the intervention did not come to the emergency room any sooner than patients who did not receive the intervention.

Q: What knowledge did the patients get, and how did they get it?

Dracup: The instruction was a one-to-one educational instruction that went for about 45 minutes or an hour. There were graphs and drawings to help the patients understand the pathology, the way that heart disease works. And then some explanations about the steps to take when heart attack symptoms occur. And the benefits that would occur if the patient sought care quickly.

Just for some background, let me say that the importance of seeking care quickly really lies in the ability to prevent sudden death outside of the hospital, and also to reduce the complications that come with a heart attack. So patients need to act right away, get to the hospital within 30 minutes, and the ideal is to be treated within an hour. Our patients took two hours to decide and get themselves to a hospital.

Q: What happened in the first six months that did not happen later?

Dracup: We’re not sure why, but the patients who were in the experimental group, who received the special instructions, were more likely to call 9-1-1 or the emergency medical system within the first six months after the instruction, and those in the control group had no change in the behaviors. So we do think that for at least some period of time out from the instruction, patients do remember and it is a little bit more poignant for them. So they were more likely to call 9-1-1.

Q: Why would patients who know the symptoms – and therefore can figure out that they may be having a heart attack – not call for care?

Dracup: The research about patients who have already had a heart attack is so intriguing. Patients who have already experienced their first heart attack delay just as long for their second heart attack. And you would think, “Well, they’ve already had the symptoms, they’ve been treated successfully, they must know how important it is to get to the hospital.” And yet, they delay just as long as someone who has never had a heart attack.

We don’t know exactly why, but when we’ve interviewed patients, what they’ve told us is that they have labeled the symptoms as something different. The tiredness was, of course, always hard to interpret. Maybe they were getting the flu. If they had a heaviness, or difficulty, some discomfort in their chest, they hoped it was something they ate - you know, attached to their stomach, not their heart. They had lots of interpretations that supported the symptoms as being related to anything but their heart.

Also, patients have told us that they are embarrassed. Some patients, of course, who don’t have insurance, are worried about the finances. Some women have said how worried they are about the people they take care of, spouses or children or others in the family. And so they didn’t want to tell anyone that they thought they were having a heart attack, so they stayed home more hours. So, it is very problematic. People have lots of reasons to not want to admit that these are heart symptoms.

Q: Based on your study, what would you recommend these patients do, and why would you recommend that they do it?

Dracup: When patients first experience anything that seems like heart attack symptoms—those symptoms are well known and are on all of the websites; if you put in heart attack symptoms, you’ll get wonderful websites telling you what you’ll feel if you have heart attack problems—you should call 9-1-1 immediately. It’s very important that the people who come with the emergency medical system can identify that this is a cardiac problem. They call ahead to the emergency room. You’re more likely to get treated quickly once you get to the hospital. So I think that the number one message is, if you think you’re having a heart attack, call 9-1-1.

Another important message is that, if you seek care quickly it can change your life. We have the treatment, the drugs, the procedures, to essentially reverse that process that is taking place in your heart. Where, if it is not reversed, muscle dies and you will in fact have a different life. But you can avoid that by calling 9-1-1 and seeking care quickly.

Q: Is there anything else you want to add?

Dracup: I think, as researchers, we all are struck once again that giving patients knowledge—they all learned in this, they all benefited from the intervention in the sense of learning a lot more about heart attack symptoms—we’re humbled by how hard it is to change behavior. So I think that anything that physicians and nurses working with this population can do to help patients and their family members really understand the importance of getting to the emergency room as soon as possible is really the critical point.